Results of Surgery in General Surgical Patients Receiving Warfarin: Retrospective Analysis of 61 Patients

The aim of this study is to investigate postoperative complications, mortality rates, and to determine the factors affecting mortality on the patients receiving warfarin therapy preoperatively, as well as comparing the results obtained from emergency and elective surgeries. Surgical outcomes of 61 patients on long-term oral anticoagulation with warfarin who underwent surgery in our center were retrospectively reviewed over an 8-year period. Thirty-three (54.1%) patients were female, with a mean age of 53 years. Mitral valve replacement (62.3%) was the most frequent indication for chronic anticoagulation therapy. Twelve out of 61 (19.2%) patients underwent emergency surgery; 59 (96.7%) operations were classified as major surgery. We did not observe any thromboembolic events on patients receiving our bridging therapy protocol. Cardiopulmonary dysfunction (CPD; 19.7%) and hemorrhage (16.4%) were the most encountered postoperative complications. Presence of CPD, bleeding, endocarditis, and mortality were statistically significant for emergency surgeries when compared with the results obtained from elective surgeries. There were 5 (8.2%) deaths observed during follow-up. It was found that advanced age, prolonged duration of operations, and presence of CPD had a statistically significant effect on mortality (P < 0.05). The patients receiving oral anticoagulant had high postoperative complication and mortality rates. This case was more evident in emergency surgeries. It is recommendable that as mortality is more apparent in the patients who undergo emergency surgeries—being older, having long duration of operations as well as CPD. Therefore during the postoperative follow-up process, the patients should be closely monitored.Key words: Emergency, Postoperative complications, Morbidity, Mortality, WarfarinThromboembolism is a major global health concern contributing to more than 0.5 million deaths in Europe and up to 300,000 deaths in the United States each year.¹ Versatile arrays of anticoagulant and/or anti-aggregant agents are available. They are used to treat and prevent thrombosis occurring as a result of venous stasis, valvular heart disease, prosthetic valves, atrial fibrillation, or myocardial infarction. After using these medications, patients who require elective or emergency surgery represent a specific population; moreover, they are prone to developing either excessive bleeding or thrombosis.The annual incidence of major bleeding as a result of oral anticoagulant (OAC) use is reported between 2 and 5%.² Patients on OAC may require elective or sometimes emergency surgical or invasive procedures. There is no consensus on standard protocol to follow for those who require perioperative management.³In the current literature, there are limited numbers of studies regarding the discussions about the operations in general surgery patient population receiving warfarin treatments. In this retrospective study, our aim was to document the complications and outcomes of general surgical procedures implemented on patients receiving warfarin. Along with the comparison of the emergency and elective surgeries performed, we also aimed to determine the factors affecting mortality.     

Ultrastructural analysis of human umbilical cord derived MSCs at undifferentiated stage and during osteogenic and adipogenic differentiation

Mesenchymal stem cells (MSCs) are considered as an important tool for regenerative medicine and experimental treatments. Unveiling the ultrastructural changes during the differentiation of MSCs might help us to understand the nature of the process and to develop novel therapeutic approaches. For this purpose, human umbilical cord (hUC) was chosen as MSC source. In the first place, MSCs were isolated from sub-amniotic, intervascular and perivascular areas of hUC by enzymatic and tissue explant method to determine the most favorable region of hUC and technique for further processing. Therefore, microscopic and growth kinetics analyses showed that there was no clear difference in the morphologies and proliferation rates among the hUC-MSC groups. Flow cytometric analysis showed that CD44 and CD90 MSC markers were highly expressed, while CD34 and CD45 hematopoietic stem cells markers were expressed at low degree. Because our preliminary results showed that there was no conspicuous superiority among the hUC-MSCs groups, whole UC was utilized as a source, and tissue explant method was applied to isolate MSCs for further differentiation analysis. At the 1^st and 3^rd week of osteogenic and adipogenic differentiation, ultrastructural analysis showed an increase in the number of secondary lysosomes in comparison with the undifferentiated status. Increase in the mitochondrial content was also detected at the 1^st week of adipogenic differentiation. Consequently, ultrastructural changes including increase in the number of mitochondria and secondary lysosomes during the adipogenic and osteogenic differentiation could be attributed to the switch in energy metabolism of the MSCs and increment in the lysosomal activity respectively.     

Vesiculopustular Eruption in Neonatal Transient Myeloproliferative Disorder

Transient myeloproliferative disorder (TMD) typically presents with pancytopenia, hepatosplenomegaly, and immature circulating white blood cells, and affects approximately 10 % of neonates with Down syndrome. The authors report a neonate with Down syndrome who developed acute widespread pustular eruptions as a sign of TMD. The white blood cell counts on the first day of life were markedly elevated, with blasts seen on examination of the peripheral blood smear. And the patient was noted to have a few erythematous papules and pustules especially on the face. On the following days pathergy positive crusted papules and pustules were increased and spread to trunk and extremities. Skin biopsy specimens showed pustular dermatitis, with subcorneal vesiculopustules and perivascular inflammation in superficial dermis. These lesions improved parallel with the hematologic improvement within two weeks. The authors aim to alert clinicians about this uncommon cause of vesiculopustular eruption with the present illustrative case and review the literature.